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Sunday, June 28, 2015

A wonderful perspective about metzitzah is presented below.
Sadly it will be ignored by the right wing community that has turned this issue into dogma, that has equated this ancient and halakhically unnecessary practice with those that originate from Sinai.

In the end of the day, the practice is a Chillul Hashem.

It turns Jews away from Bris Milah, either completely, or opting for hospital circumcisions which are often before the eighth day of life.
It turns non-Jews into people who degrade Judaism and its practitioners.
And it is near impossible to justify in the realm of modern sensibilities (and there are halakhic alternatives!).

It's not as if there isn't history to metzitzah being problematic. And even right-wing rabbis coming up with an equitable solution which maintains metzitzah (for those that require it) while doing it in a way that is hygienic and antiseptic AND halakhically acceptable. (Even though if pushed most would probably admit that metzitzah is not a necessary component of bris milah, certainly not on the level of the circumcision itself).

I don't pay attention to those who says "It's time for the Jewish people to get with the times and stop circumcising their sons." These people are ignorant of the Covenant and our attachment to it. They often "think" they have a solution, which they call a Brit Shalom, but they have made up a ritual that ignores everything that is written in Bereshit 17 about Avraham's descendants and God.

As Jewish physicians we feel a special responsibility to speak out on health matters that uniquely affect the Jewish community. The policy recently adopted by the City of New York to respond to herpes simplex virus (HSV) infection risk as a result of a certain form of ritual circumcision is inadequate. For Jewish medical professionals to remain silent during this discussion would be, in our judgment, inappropriate.

HSV, which commonly causes “cold sores” and genital herpes, can result in death or permanent disability in newborns.

There have been multiple cases of newborn males with laboratory-confirmed HSV infection following out-of-hospital Jewish ritual circumcision. There is strong evidence that in the majority of these cases the infection was associated with metzitzah b’peh, in which the mohel places his mouth directly on the newly circumcised penis and sucks blood away from the wound (direct orogenital suction, abbreviated as DOS). This represents an ancient practice, but since the formulation of germ theory in the 1800s the overwhelming majority of traditional ritual Jewish circumcisions no longer employ this practice, instead using alternative methods of suction. Some members of the charedi community continue the practice of DOS.

Keeping a campaign promise, Mayor de Blasio has rescinded the requirement that parents give written consent prior to the performance of DOS on their newborns. Instead, when a baby contracts HSV following DOS, if the mohel is proven to have the same HSV strain as the infected baby by DNA testing, then the mohel will be banned for life from the practice. It can sometimes require multiple DNA tests to establish a match.

We think the policy is insufficient.

Circumcision is surgery and can transmit infection if not performed under antiseptic conditions. Oral contact with an incision by a person who is an HSV carrier, even if he is unaware of an open sore, risks transmission of HSV and other pathogens. Alternative means exist by which blood may be drawn from a circumcision wound such as a sterile glass tube or sterile gauze.

Several arguments have been voiced either in defense of DOS or to mitigate concern. The ones we, as physicians, are least qualified to respond to are theological. Genesis [17:10-11] instructs “every male child among you shall be circumcised. ...” The Babylonian Talmud states that “if a mohel does not perform suction, that is deemed dangerous and he is to be dismissed.” While defenders of DOS will invoke an interpretation of the Talmud passage to support it, the overwhelming majority of Orthodox rabbinic rulings — as well as those of the other religious streams — either deem DOS as being inconsistent with Jewish law and contemporary knowledge of hygiene or, at the least, acknowledge that removing blood by other means, such as with sterile gauze or a sterile glass tube, is preferable.

Additional arguments have been voiced in defense of DOS. The first is that, according to some New York infectious disease specialists, the link between HSV and DOS and newborn death or severe brain injury has “not been proven.” Those holding such view seem unpersuaded by the detailed analyses published by the U.S. Centers for Disease Control (CDC), which establish the link and the ratio of newborn infections of HSV type 1 v. type 2. Scientific evidence supporting the causal link between DOS and HSV was recently reviewed by six members of the Albert Einstein College of Medicine faculty in the Journal of the Pediatrics Infectious Disease Society. If individuals, however, are not persuaded by sound virology and epidemiology research, we would bet that no adult who understands the transmission of disease by microbes would consent to a human being’s putting their mouths upon a fresh surgical incision.

The second argument is the assertion that, if a mohel rinses his mouth with wine or an antiseptic mouthwash, the risk of HSV infection by DOS is eliminated. While prolonged exposure to alcohol in a laboratory Petri dish can indeed inactivate HSV, any claim that a dilute alcohol swish in the mouth, with its multiple nooks and crevices, will prevent HSV infection is fanciful.

The third argument is that the new NYC policy represents a reasonable compromise, protecting an individual’s right to practice his/her religion while employing the tools of public health to limit the spread of disease. But allowing some babies to suffer the consequences of HSV infection before taking any action against the offending mohel, who must be proven to be the culprit by DNA testing, is not a preventive public health measure. It is too little, too late. DOS violates a baby’s right to be protected from an obvious impending harm. The government has an overriding interest in protecting infants who cannot speak for themselves.

DOS ignores the teachings of modern medicine and the overwhelming consensus of modern rabbinic rulings. Behavior by mohelim and local politicians that ignores fundamental principles of hygiene, and abrogates their responsibility to protect innocent children, is shameful and simply wrong, despite their express desire to maintain ancient religious traditions.

The Jewish medical community should strongly affirm its respect for religious pluralism and sectarian particularism. It should dedicate itself to working with rabbinic leaders to make them aware of the unequivocal scientific and medical facts about the dangers of DOS and the urgency of using existing safe and acceptable alternatives. Moreover, we urge our political leaders to go on record supporting this approach.

We perform all the needs of circumcision on Shabbos. We circumcise, uncover the corona, and draw out the blood; then place a compress and cumin on it. If he did not crush the cumin before Shabbos, he chews it with his teeth then applies it. If he did not mix together the wine and oil on Friday, he applies each one separately. We may not prepare a new bandage, but a rag can be wrapped around it. If it wasn't brought to the place of the Bris in advance of Shabbos, he can wind it around his finger and bring it [to the bris] - even from a different courtyard.

The key phrase is the first one: we do everything that is necessary for the bris itself, meaning the moment of the actual circumcision. Many things that are done during a circumcision are otherwise a violation of Shabbos: the instruments are muktzeh, causing a wound, marking where the foreskin is, etc/

What is Different At a Shabbos Bris?

The main difference is in the immediate aftermath of the circumcision. If the mohel notices that there are tzitzin she'einan m'akvin - portions of the skin or membrane that might be a little asthetically unpleasing but are not on the glans - they may not be removed/cleaned up on shabbos. If, however, these leftovers would render the bris unkosher, then they could be removed on Shabbos, in the immediate aftermath of the bris.

Anything Else?

Once the circumcision instruments are used and no longer needed, they become muktzeh. If the mohel can leave his things in a safe place where they won't get misplaced or accidentally taken, he should do that, rather than take them home with him.

Finally - an older mohel told me this one long ago - if the mohel is inconvenienced in any significant way, on account of his having to leave his family for shabbos for example, it is certainly appropriate for the bris family to make arrangements for where he'll stay (if he can't on his own), and compensate him for his travel, bris services, and time away.

Thursday, June 11, 2015

Most of what is written here is true for both boys and girls. Owing to
the nature of this blog/website, the essay is written in the masculine.

Aside from bringing children into this world, parents have the awesome
responsibility of giving each child a name. Some names speak to the
significance of the baby in the lives of his parents, or a reflection of his
personality. Sometimes he is named for a loved one - depending on the family's
custom, the honored name might be carried by a living person, or it comes from
someone who is deceased.

Some people decide their baby’s name months in advance of his birth. Others
wait for the inspiration to come after the baby is born.

How does one choose a name?

Honestly, every couple has to find a method which works for them. And
they should agree upon the method and the name, and be happy with their
decision. I have spoken to people months after a bris, asking “how is ___
doing?” only to be told that that is no longer his name. It didn’t feel right.
Hopefully this is not the experience most people are having (in my experience
it is very rare, but it does happen).

Some Sefardic cultures honor a living grandparent by giving the
first grandchild the name of that grandparent – either as a first name or as a
middle name. In the book Yalkut Yosef, the author says the name of the paternal
grandfather takes precedence over the maternal grandfather, but he also says
such a preference is not binding. (Some parents come from different cultures –
especially in a “mixed” Ashkenazic wife/Sefardic husband situation.)

If a child is to be named for someone who is deceased, the choice is
relatively simple when the same name is being given. When the exact name is not
being transferred to the child, it becomes more complicated (see below).

If parents are choosing a name they like, it’s a relatively simple matter as
well.

It becomes a little more complicated when parents are looking to be “inspired.”
But, like many important decisions in life (such as when you decide to get
married), when you feel it’s right, you know it’s right.

Different Names For the Same Child

Some parents put a child’s Jewish name on a birth certificate. Others put an
Anglicized version of the name (such as Samuel for Shmuel, Gabriel for Gavriel,
Jacob for Yaakov) on the birth certificate. Others put a related name (Max for
Mordechai, Dylan for David). Still others have completely different “English
names” than their Jewish names. Rex Ryan = Moshe Aharon. My uncle’s name is
Michael, but his Hebrew name is Binyamin.

When Naming For Someone But Not Giving the Exact Name

My great grandfather’s name
was Chuna – a Yiddishized diminutive of Elchanan. My parents wanted to give me
the Hebrew form of the name, so my middle name is Elchanan. This kind of thing
happens all the time.

Gramps was named Mottel – a
Yiddish version of Mordechai. The parents loved Gramps, but don’t want to name
their child Mottel. They might stick with Mordechai. If not, they’ll typically
want to keep the initial, so they might opt for a modern name that begins with
M: Matan, Matanya, Ma’or or a simple classic such as Moshe or Meir.

Sometimes a boy will be
named with great grandma in mind. Her name was Mary. Mary sounds like Meir.
Meir also sounds like Miriam. The Biblical Miriam was Moshe’s brother, another
option. Or Grandma’s name was Rose. Rose becomes Reuven or Ronen, etc

Who Gets to Choose the Name?

The baby’s parents. No one
else.

A Good Rule

A friend of mine told me
that he accepts and welcomes all name suggestions from family (new baby’s
grandparents, for example) until the end of the second trimester of the
pregnancy. This is an excellent rule. The people who are not the parents get to
have their say. Then the parents can decide what they will do.

A Story

In Rabbi Herschel Schachter’s
book “Nefesh HaRav,” he recounts how the subject of his book, Rabbi Joseph B.
Soloveitchik, was given his name Yosef Dov/Yusher Ber.

Rabbi Chaim Soloveitchik,
the famous Brisker Rov, and grandfather of the new baby, came to speak with his
daughter-in-law, the baby’s mother. He told her that according to the custom
and the law she (as the mother) has every right to name the baby after whomever
she wants, or in whatever manner she wants (the mother gets first rights, even
over the father).

And he also told her that
to date no one had been named for his father, the Beis HaLevi, Rabbi Yosef Dov
Soloveitchik, who had died 11 years earlier.

It is important to
interrupt this story with two fun facts: 1. R’ Chaim was known to be squeamish.
He did not like to serve as Sandak. 2. It is a great honor for parents, if the
baby’s grandfather serves as Sandak, holding the baby during the actual
circumcision. In general, it is customary to honor a person whose character
traits and Jewish life are honored and respected by the parents to be the
Sandak.

R’ Chaim told her that if
she would agree to name the child after his father, he would agree to be
Sandak, even though it was a role he shied away from.

She agreed. Apparently
having R’ Chaim serve as Sandak was more important to her than her own choices
of names she may have conferred onto her baby. He was named Yosef Dov/Yusher
Ber, just like his great grandfather.

The point of the story is
not that R’ Chaim got his way. It’s that he knew he didn’t have to get his way.
He wasn’t supposed to get his way. His daughter in law did not have to agree or
listen to his suggestion. It wasn’t his call. And he was going to be OK with
that – he just wouldn’t swallow his squeamishness and serve as Sandak if they
chose to go a different route with the baby’s name. Which would have been fine.
Someone else would have been the Sandak.

In Conclusion

It is certainly a wonderful
honor to name a child either after a living person or after a deceased loved
one or ancestor.

But the parents of the baby
must never feel pressured to give their child a name they don’t want to give.
Naming a child is a privilege afforded to parents, and as they bring the child
into the world, they and they alone have the final say in the baby’s name.

Too many times have I seen
the new parents compromise on the name they end up giving their child, against
their own wishes, on account of the pressure they feel from their own parents.

If they choose to honor a
loved one and give a child the name that has been in the family, that is
beautiful. That is wonderful.

If they do not, it says nothing
of their relationship with that deceased individual, or with the kin of the
deceased.

All it says is that they
wanted a different name for their child. And that they exercised their rights
as parents to give him the name they wanted to give him.

I bless all parents and
grandparents to love all of their children unconditionally. When your children
choose to name your grandson using a name that is emotionally meaningful to
you, be grateful. If they do not choose such a name, they are not being hurtful
or malicious. They are giving their child the name they wanted to give their
son. Your grandson will be loved by you all the same. It is not worth making
any kind of protest. And hopefully you’ll live long enough that your grandchildren
will never have a need to name anyone after you (unless you are Sefardic).

Wednesday, June 10, 2015

Sometimes a baby is born with an anatomical condition that does not allow for a traditional bris.

Here are layman's terms for some of these circumstances. Understand that these situations are a result of how the baby develops in utero, and are not a reflection of anything wrong with the baby or his parents. In some cases, this kind of development is genetic.

Thank God we live in a time in which highly skilled surgeons can make a relatively easy job of fixing the baby's genitalia, so he will not only have a beautiful circumcision, but in cases where certain elements of functionality would have been a little off, the correction is nothing short of miraculous. In a different time, some of these babies would not grow up to become fathers.

1. No foreskin

If a baby develops without any skin covering the glans, there is nothing to remove. The only procedure is Hatafat Dam Brit - drawing a minimal amount of blood from where the foreskin would have been, just above where the glans begins (not from on the glans itself).

2. Hypospadias

This is the condition in which the hole of the penis - the urethra - is not where it should be. It could be a little off center on the tip of the glans. It could be below the glans. Or in more extreme (and very rare) cases, it could be anywhere on the shaft or even the scrotum. Depending on the severity of the case, reconstructive surgery would align everything properly and allow for a productive future. If the hole is on the shaft or the scrotum, a boy would always have to sit when going to the bathroom, and he would never be able to be a father. (If it's only a little off center, most surgeons would recommended leaving it alone).
In the event that surgery would be required here, the surgeon needs as much skin as necessary. If the plan is for there to be a circumcised look afterwards, the surgeon will know this and will produce that result. But anything a mohel might do in a classic circumcision would do more harm than good for the baby.
[In most surgery-required-hypospadias cases I've seen, the hole is at the bottom of the glans, at the spot where the frenulum is.]

3. Chordee

The natural position the penis takes when erect is upward. In simple terms, chordee prevents that, as internal tissue pulls the erection downward, and even makes a downward curvature.

THERE ARE OTHER CONDITIONS AS WELL, BUT THESE ARE THE MOST COMMON

So What Is Done With the Bris?

There is no bris. The circumcision will be taken care of during surgery. The best route is to find a Jewish doctor (ideally observant), who will say the proper bracha (blessing) and have in mind the fulfillment of the mitzvah. If the surgery is not done by a Jewish doctor, the circumcision can be turned into a "Bris" through Hatafat Dam Brit, after everything has healed.

What About Family and Friends Who Are Looking to Attend a Bris?
They should be understanding that the baby's best interests do not include a formal bris. They don't need to know all the details. Some people are embarrassed to discuss the baby's circumstance. But it's really nothing to be embarrassed about. No one has done anything wrong. And the baby will be fine. And everything will work properly after the surgery.

Parents will do well to inform their family and friends something along the following lines:

Dear Family and Friends

After consultation with doctors and mohels, we have determined that a formal bris is not in our son's best interest. He is fine. He will have a proper bris - הראוי לו ובזמנו - for his particular needs at the right time.

In the meantime, we will be naming him at such and such time and place, and we would be honored if you would join us then (or at a different time) when we have a fitting celebration for his arrival.

Welcome to Mohel in South Florida

I am a mohel here to serve you, ready to tailor the ceremony to your particular needs. I will treat you with the dignity you, new parents, deserve; you are bringing your son into the mark of the Covenant - obvious to some, but not an easy decision for all.